Patient Data

Exhibits

Nurse analyzes the findings.

Which can the nurse do to mitigate artifacts when performing auscultation? Select all that apply.

Document the roaring and crackles

Wet the chest hair before auscultating

Keep the examination room warm, and warm the stethoscope

Reach under a gown to listen and take care that no clothing rubs on the stethoscope

Ensure the room is as quiet as possible

Answer and Explanation

Correct Answer : B,C,D,E

A.   Documenting the roaring and crackles is important to note any abnormal findings. However, this does not directly mitigate artifacts, which may interfere with the accuracy of the sounds heard through auscultation.
B.   Wetting the chest hair is a useful technique to reduce the sound interference caused by chest hair rubbing against the stethoscope. This helps eliminate some of the unwanted sounds and improves the clarity of auscultation.
C.   Ensuring the room is warm and the stethoscope is warmed before use is important because cold stethoscopes can cause discomfort to the client and may lead to muscle tensing, making it harder to hear clear heart and lung sounds.
D.   Reaching under the gown ensures that no clothing creates friction on the stethoscope, which can produce unwanted sounds during auscultation. This helps in obtaining clear and accurate heart or lung sounds.
E.   A quiet environment is crucial for auscultation, as background noise can obscure important sounds. Ensuring that the room is free from distractions and noise will significantly improve the quality of auscultation.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. A mole that changes color and size is concerning for melanoma, a type of skin cancer. Immediate evaluation by a healthcare provider is essential for diagnosis and possible biopsy.
B. While sun exposure can increase the risk of skin cancer, the priority is to have the mole evaluated by a healthcare provider rather than focus on past behaviors.
C. Encouraging self-monitoring is not a priority when the mole shows signs of malignancy.
D. Teaching family members to monitor is secondary to seeking professional evaluation.

A. Normal reflex response for age. B. Exaggerated reflex response. C. Beginning meningeal irritation. D. Pyramidal tract disease.

Correct Answer is D

Explanation

A. An extension of the great toe and fanning of other toes is known as a positive Babinski sign, which is abnormal in adults. This response is typically seen in infants but indicates neurological damage or dysfunction in adults.
B. An exaggerated reflex would usually refer to hyperreflexia, but the Babinski sign specifically involves the abnormal extension of the toes, not just an exaggerated reflex. This response is more associated with neurological damage than simple exaggeration.
C. The Babinski sign can sometimes be associated with central nervous system issues, including meningeal irritation. However, meningeal irritation often involves other symptoms such as neck stiffness, fever, and photophobia, which are not mentioned here.
D. A positive Babinski sign is a classic indication of pyramidal tract disease, which affects the corticospinal tract. This type of neurological dysfunction can be seen in conditions like stroke, multiple sclerosis, or brain injury.

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Patient Data Exhibits Nurse analyzes the findings. Which can the nurse do to mitigate artifacts when performing auscultation? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client asks the nurse to look at a mole located on the back. The client tells the nurse that the mole has changed from brown to black and enlarged in size. Which is the priority nursing action?

Correct Answer is A

Explanation

When assessing the left foot planter reflex of an adult client, the nurse observes an extension of the great toe and fanning of other toes. Which interpretation of this finding is accurate?

Correct Answer is D

Explanation

Which assessment finding, obtained during chest auscultation, should the nurse consider a normal finding?

The nurse observes that the lower legs of a client with diabetes mellitus are shiny, and with no hair growth. To obtain additional data to support these findings, which assessment should the nurse perform?

Patient Data Exhibits Nurse analyzes the assessment findings. Click to indicate which findings are indicative of rheumatoid arthritis or are not applicable to that disease. Each row must have only one response option selected.

When conducting a physical examination, the nurse is assessing a client's abdomen and identifies a centrally localized distention that is pulsating. This finding should direct the nurse to consider which pathology?

A client states, "I am legally blind." Which assessment technique should the nurse use to obtain subjective data to support the client's statement?

The nurse is assessing a client who has a history of kidney stones and returns to the clinic with flank pain. Which intervention should the nurse implement first?

Patient Data

Exhibits

Nurse analyzes the findings.

Which can the nurse do to mitigate artifacts when performing auscultation? Select all that apply.